Alternatives to acute hospital admission in adult mental health
Submitting InstitutionUniversity College London
Unit of AssessmentPsychology, Psychiatry and Neuroscience
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
Alternatives to acute admission in mental health are crucial, not least
because of the high cost of inpatient care. We have carried out a major
research programme that includes the only randomised controlled evaluation
of crisis resolution teams and the only major UK study of crisis houses,
which are community-based, residential alternatives to hospital admission.
This programme demonstrated the efficacy of community treatment and has
significantly influenced decision making at a local and national policy
level, including commissioning guidance and three sets of NICE guidelines.
This has contributed to changes in the way acute services for severely
mentally ill adults are configured in the NHS, and internationally.
Psychiatric hospitals are still a prominent component of UK mental health
systems despite the closure of large asylums: the Information Centre for
Health and Social Care estimates that 550,000 of England's 1.6 million
users of specialist services for people with severe mental health problems
(such as schizophrenia or bipolar disorder) were admitted to hospital
during the year from April 2012. The high associated costs (£655 million
for acute psychiatric wards for adults of working age in 2012/13), service
users' reluctance to be admitted and reports of negative experiences in
hospital, and doubts about the therapeutic quality of wards drive the
quest for effective alternatives to admission. UCL has led nationally and
internationally over the past decade on research on these. Led by
Professor Sonia Johnson, we have researched both major current types of
alternative: crisis resolution teams, which provide crisis assessment and
intensive home treatment, and crisis houses, which provide a community
residential alternative to admission.
A national policy in the UK mandated the introduction of crisis teams
in 2001. This was widely criticised for lack of evidence, as studies cited
to support it were at least two decades old and conducted in a very
different service context from the current NHS. Our research has provided
the necessary underpinning for their continuing implementation and
development in the NHS. Our initial study on crisis teams was a
naturalistic investigation of the impact of their introduction .
This was followed by a widely cited study that remains internationally the
only randomised controlled trial of the crisis resolution team model in a
deinstitutionalised service system  accompanied by a health
economic study demonstrating cost-effectiveness .
Subsequently Johnson has led a nationwide investigation of the impact on
the workforce of working on acute wards and in crisis teams .
Norway has now followed England in adopting crisis teams as a national
model, and Johnson has participated in a multicentre study assessing the
Norwegian implementation. Our programme of research on crisis teams
continues through the CORE study (2011-16), funded by the National
Institute for Health Research Programme Grants for Applied Research. The
initial stage of this has involved a nationwide investigation of
experiences of implementing the crisis team model and of how best practice
may be achieved in these teams: we are now conducting a national pilot of
a fidelity scale based on the resulting model of good practice.
The second form of admission diversion we have investigated is the crisis
house, which provides 24-hour support and treatment in a domestic,
community-based setting. Despite a 50-year history and strong support from
service users, evidence for effectiveness and potential role in the mental
health care system was limited prior to the studies of the past 10 years
in which UCL has participated, so that they featured little in mental
health policy and guidance on service planning. Following an initial study
of service user characteristics and experiences in a women's crisis house
in North London, we have, in collaboration with colleagues at Kings
College London, conducted the study that is now the main UK evidence
source on residential alternatives to acute admission, the Alternatives
Study [5, 6]. This demonstrated that crisis houses manage in the
community a group that overlaps substantially with acute hospital ward
populations, though with less risk to others in acute wards. We have also
found that service users prefer crisis house care to inpatient admissions,
and that it is associated with lower mean costs and similar subsequent
References to the research
 Johnson S, Nolan F, Hoult J, White IR, Bebbington P, Sandor A,
McKenzie N, Patel SN, Pilling S. Outcomes of crises before and after
introduction of a crisis resolution team. Br J Psychiatry. 2005
 Johnson S, Nolan F, Pilling S, Sandor A, Hoult J, McKenzie N, White
IR, Thompson M, Bebbington P. Randomised controlled trial of acute mental
health care by a crisis resolution team: the north Islington crisis study.
BMJ. 2005 Sep 17;331(7517):599. http://doi.org/bbzth9
 McCrone P, Johnson S, Nolan F, Pilling S, Sandor A, Hoult J, McKenzie
N, Thompson M, Bebbington P. Economic evaluation of a crisis resolution
service: a randomised controlled trial. Epidemiol Psichiatr Soc. 2009
 Johnson S, Osborn DP, Araya R, Wearn E, Paul M, Stafford M, Wellman
N, Nolan F, Killaspy H, Lloyd-Evans B, Anderson E, Wood SJ. Morale in the
English mental health workforce: questionnaire survey. Br J Psychiatry.
2012 Sep;201(3):239-46. http://doi.org/pbt
 Johnson S, Gilburt H, Lloyd-Evans B, Osborn DP, Boardman J, Leese M,
Shepherd G, Thornicroft G, Slade M. In-patient and residential
alternatives to standard acute psychiatric wards in England. Br J
Psychiatry. 2009 May;194(5):456-63. http://doi.org/dcr7bv
 Osborn DP, Lloyd-Evans B, Johnson S, Gilburt H, Byford S, Leese M,
Slade M. Residential alternatives to acute in-patient care in England:
satisfaction, ward atmosphere and service user experiences. Br J
Psychiatry 197:s41-s45 http://dx.doi.org/10.1192/bjp.bp.110.081109
Peer reviewed funding
• Evaluation of a Women's Crisis House (1999-2002): S. Johnson (CI), S.
Pilling, P. Bebbington, J. Dalton, S. McNicholas. London Region Research
and Development Responsive Funding Committee. £68,000
• The Alternatives Study (2005-2009): S. Johnson and M. Slade (Joint
CIs), G. Thornicroft, J. Boardman, D. Osborn, N. Morant, G. Shepherd, V.
Pinfold, S. Byford, M. Leese. NHS Service Delivery and Organisation
• National Acute Care Research Group (2006-) Convened by S. Johnson.
Mental Health Research Network Group, awarded by national competition.
• Pilot patient preference trial of women's crisis houses (2006-2009): L.
Howard (IOP - CI), S. Johnson, A. Boocock, M. Leese, G. Thornicroft, P.
Cutting, S. Byford. Medical Research Council. £260,000
• A national investigation of in-patient staff morale (2006-2010) S.
Johnson (CI), D.Osborn, F.Nolan, S.Wood, M.Paul, R.Araya, H.Killaspy,
S.Pilling) NIHR Service Delivery and Organisation Programme. £300,000.
• An investigation of therapeutic alliance and its relationship to
service user satisfaction in acute psychiatric wards and crisis
residential alternatives (2011-2013) S. Johnson (CI), B. Lloyd-Evans, R.
McCabe, M. Slade, H. Gilburt, F. Nolan, N. Morant). NIHR Service Delivery
and Organisation Programme. £135,000
• Optimising team functioning, preventing relapse and enhancing recovery
in crisis resolution teams: the CORE programme (CRT Optimisation and
RElapse prevention (2011-2016). S. Johnson (CI), T. Weaver, R. Gray, C.
Henderson, O. Mason, B. Lloyd-Evans, D. Osborn, F. Nolan, A. Faulkner, N.
Morant, L. Addison, S. Morris, S. Onyett. National Institute of Health
Research Programme Grant. £2,005,000
Details of the impact
The principal contribution of this programme of work has been to provide
an evidence base for informed decision making at local and national policy
levels regarding the configuration of acute services for severely mentally
ill adults. Our work has been widely cited, and has contributed towards
sustaining the crisis resolution/home treatment model beyond the initial
period when it was mandatory national policy, and towards supporting the
introduction of new residential crisis houses in the community. The
benefits of a policy on acute mental health care that is well founded in
evidence are considerable: the Information Centre for Health and Social
Care estimates that acute inpatient wards cost £655 million per year and
crisis resolution teams £256 million in England. Effective alternatives to
acute admission represent significant cost savings to the NHS and
furthermore improve an aspect of service provision that users frequently
cite as one of the most important issues for them, and the one with which
they are least satisfied.
Guidance for Commissioners: The Joint Commissioning Panel
for Mental Health, co-chaired by the Royal College of Psychiatrists and
the Royal College of General Practitioners in collaboration with a range
of national voluntary and statutory bodies, has produced recommendations
on adult mental health services which are intended for use by Clinical
Commissioning Groups to inform local commissioning priorities, strategies
and service redesign; and for Health and Wellbeing Partnerships to inform
Health and Wellbeing Strategies. Their guidance on services for severe
problems in crisis cites our work in its recommendations that: crisis
teams are an efficient way of managing mental health crises; that they can
also be used in early psychosis; and that crisis houses are beneficial for
a sub-group in crisis. Johnson was part of the expert group making these
recommendations [a]. The NHS London commissioning programme also
produces guidance on acute care models and cites our work in support of
recommendations on crisis teams and crisis houses [b].
NICE Guidelines: Our work is cited in guidelines on bipolar
disorder, schizophrenia and service user experience. Bipolar disorder:
our study is cited as the main evidence to support a recommendation that
crisis teams be made available for people with bipolar disorder [c].
Schizophrenia: the current (2009) guideline on schizophrenia cites
our trial (paper 1) as evidence that crisis teams may reduce
hospitalisation for people from Black and Minority Ethnic backgrounds as
well as for White service users [d]. In the 2013 revision of the
NICE guidelines, for which Johnson is on the Guideline Development Group,
evidence on mental health teams has been reviewed in more detail, and our
trial (paper 1) will be cited as the only recent evidence supporting the
recommendation that crisis resolution teams be available for people with
schizophrenia/psychosis. Our work on crisis houses (papers 4 and 5) is
also discussed. This guideline is now at a late stage of drafting, for
release in late 2013. Service user experience in adult mental health:
cites our work on crisis houses to support a recommendation that these
should be available as they are greatly preferred by service users [e].
Reports by national voluntary sector bodies: Several recent
reports by influential national bodies cite our work in support of their
recommendations. The national mental health charity MIND has
conducted a national enquiry into acute care and is conducting a
subsequent report on acute care. The enquiry report cites our studies in
support of its strong advocacy of the crisis house model. Subsequently
Johnson and colleagues have collaborated with MIND on their acute care
report: Johnson has appeared with MIND representatives to give evidence on
acute care to the All Party Parliamentary Group on Mental Health. We have
released to them early findings from our national survey on crisis teams
in the CORE study and these have formed the basis of recent press releases
and media coverage on acute care [f]. The Kings Fund has
recently reported on ways of enhancing the productivity of mental health
services. This major report cites four of our papers on crisis teams and
crisis houses in support of recommendations that alternatives to admission
need to be further developed in order to increase the efficiency and
acceptability of mental health services [g]. The think tank Centre
for Social Justice has also reported on mental health services
nationally. It advocates reform of mental health service delivery, citing
our work to support the recommendation for further development and
implementation of the crisis team and crisis houses [h].
International impact: A report by the World Psychiatric
Association making recommendations for the development of community mental
health services makes recommendations in support of crisis teams and
crisis houses in countries with well-developed mental health systems [i].
Our work is also cited in support of new national policies in documents
from Norway and Flanders (Belgium), and in documents supporting local
plans and policies within mental health Trusts. In Norway, for example,
our work influenced recommendations for crisis resolution teams in Norway,
developed by the Acute Network for the Norwegian Directorate of Health [j].
Johnson has been asked to speak on crisis teams in relation to the
introduction of new policies in Norway, Flanders, Scotland and Wales and
is regularly contacted by service planners and clinicians from a variety
of countries where this model has attracted interest.
Sources to corroborate the impact
[a] Joint Commissioning Panel for Mental Health `Mental health and
wellbeing commissioning pack', Commissioning Framework, Volume 3. Six
papers from our group are cited in the recommendations for severe problems
in crisis http://www.nice.org.uk/guidance/index.jsp?action=download&o=64924
[b] Models of mental health care for London, 2011. Cites four papers from
our group — see pages 19 and 54 http://www.londonhp.nhs.uk/wp-content/uploads/2011/03/2.-Models-of-care-low-res.pdf
[c] NICE guidelines on Bipolar affective disorder guideline (CG28).
References to our work on p. 468-9 of full guideline: http://www.nice.org.uk/nicemedia/live/10990/30194/30194.pdf
[d] NICE guidelines on Schizophrenia (2009). Cites our trial on p. 464. http://www.nice.org.uk/nicemedia/live/11786/43607/43607.pdf.
Revised guideline is also out for consultation: http://www.nice.org.uk/guidance/index.jsp?action=download&o=64924.
This cites 11 papers from our group.
[e] NICE guidelines CG 136 on Service user experience in adult mental
health (2012). Reference to our work on p. 225. http://guidance.nice.org.uk/CG136/Guidance/pdf/English
[f] Mental health crisis care: commissioning excellence. A briefing for
Clinical Commissioning Groups. Mind. November 2012. See p. 11 for
references to our work: ref. 12 our work on crisis houses; ref. 7 to early
findings released to them from the CORE programme grant.
(Copy available on request).
Minutes of the parliamentary group are
available here (and copy available on request):
Mind's crisis care report was also covered in the media: http://www.mirror.co.uk/news/uk-
[g] Mental health and the productivity challenge: improving quality and
value for money, 2010. http://www.kingsfund.org.uk/publications/mental_health_and.html
[h] Completing the Revolution: transforming mental health and tackling
poverty, 2011. Cites our work on crisis teams (Johnson et al., p. 236) and
crisis houses (Howard et al. 246) http://www.centreforsocialjustice.org.uk/UserStorage/pdf/Pdf%20reports/CompletingtheRevoluti
[i] World Psychiatric Association citing our work in review of key
European evidence on community mental health care implementation:
[j] Letter to corroborate this impact from Chair, the Acute Network,
Norway. Copy available on request.